Positive end-expiratory pressure affects the value of intra-abdominal pressure in acute lung injury/acute respiratory distress syndrome patients: a pilot study

International audienceIntroduction: To examine the effects of positive end-expiratory pressure (PEEP) on intra-abdominal pressure (IAP) in patients with acute lung injury (ALI).Methods: Thirty sedated and mechanically ventilated patients with ALI or acute respiratory distress syndrome (ARDS) admitted to a sixteen-bed surgical medical ICU were included. All patients were studied with sequentially increasing PEEP (0, 6 and 12 cmH2O) during a PEEP-trial.Results: Age was 55 ± 17 years, weight was 70 ± 17 kg, SAPS II was 44 ± 14 and PaO2/FIO2 was 192 ± 53 mmHg. The IAP was 12 ± 5 mmHg at PEEP 0 (zero end-expiratory pressure, ZEEP), 13 ± 5 mmHg at PEEP 6 and 15 ± 6 mmHg at PEEP 12 (P < 0.05 vs ZEEP). In the patients with intra-abdominal hypertension defined as IAP ≥ 12 mmHg (n = 15), IAP significantly increased from 15 ± 3 mmHg at ZEEP to 20 ± 3 mmHg at PEEP 12 (P < 0.01). Whereas in the patients with IAP < 12 mmHg (n = 15), IAP did not significantly change from ZEEP to PEEP 12(8 ± 2 vs 10 ± 3 mmHg). In the 13 patients in whom cardiac output was measured, increase in PEEP from 0 to 12 cmH2O did not significantly change cardiac output, nor in the 8 out of 15 patients of the high-IAP group. The observed effects were similar in both ALI (n = 17) and ARDS (n = 13) patients.Conclusions: PEEP is a contributing factor that impacts IAP values. It seems necessary to take into account the level of PEEP whilst interpreting IAP values in patients under mechanical ventilation

Influence du débit de gaz frais et de la technique d'induction sur la consommation et le coût de sévoflurane chez l'adulte

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Pourquoi le patient obèse morbide est-il un patient à risque anesthésique élevé ?

International audienceObesity is often associated with obstructive sleep apnea (OSA), which increases the risk of intraoperative and postoperative complications. The role of preoperative screening of OSA is crucial, with adequate management based on continuous positive pressure before, during and after surgery. The obese patient is at risk of postoperative complications: difficult airway management, acute respiratory failure following extubation due to atelectasis and airway obstruction, added to morphine overdosing. Optimal management of difficult mask ventilation and intubation, protective ventilation, combined to the reduction of sedatives and analgesics and the sitting position as soon as possible with a postoperative monitoring should decrease the occurrence of complications. Cardiovascular risk is also increased in the obese patient. Preoperative screening of cardiovascular complications with appropriate therapy, combined to per- and postoperative hemodynamic optimization with a close monitoring allow to limit the cardiovascular risk. Drug dosing titration is fundamental due to unknown pharmacokinetic and pharmacodynamics properties in obese patients. Neuromuscular monitoring should always be used whenever neuromuscular blocking drugs are used, as depth of anaesthesia monitoring, especially when total intravenous anaesthesia is used in conjunction with neuromuscular blocking drugs. Appropriate prophylaxis against venous thromboembolism (VTE) after assessment of risk benefit ratio and early mobilisation are recommended since the incidence of venous thromboembolism is increased in the obese.L’association d’un syndrome d’apnées du sommeil (SAS) à une obésité morbide est très fréquente, et induit un risque élevé de complications per- et postopératoires. Le dépistage préopératoire du SAS est crucial, ainsi que sa prise en charge spécifique : utilisation d’une pression positive continue pré-, per- et postopératoire.Le patient obèse est à risque de complications respiratoires périopératoires qui regroupent essentiellement l’accès difficile aux voies aériennes (intubation, ventilation difficile voire impossible), et les détresses respiratoires postextubation secondaires à la formation d’atélectasies ou à l’obstruction des voies aériennes, parfois associées à l’utilisation de dérivés morphiniques.Pour prévenir ces complications respiratoires périopératoires, sont conseillés : la mise en place de protocoles de ventilation au masque et d’intubation difficile ainsi que le recours à la ventilation protectrice, avec une épargne morphinique et un positionnement semi-assis tout au long de la prise en charge, associés à un monitorage rapproché en postopératoire.Le patient obèse présente également un risque cardiovasculaire augmenté. Un dépistage des complications cardiovasculaires préexistantes avec un traitement approprié en préopératoire, associé à une optimisation hémodynamique per- et postopératoire et à un monitorage rapproché permettent de limiter ce risque.Du fait d’une pharmacocinétique et d’une pharmacodynamie mal connue chez le patient obèse morbide, la titration des drogues anesthésiques est fondamentale, associée à un monitorage de la profondeur d’anesthésie surtout chez les patients curarisés chez qui un monitoring du bloc neuromusculaire est indispensable.La maladie thromboembolique étant d’incidence augmentée chez le patient obèse, une prophylaxie appropriée contre la maladie veineuse thromboembolique après évaluation du rapport bénéfice–risque et une mobilisation précoce sont recommandées

How can I manage anaesthesia in obese patients?

International audienceThe obese patient is at risk of perioperative complications including difficult airway access (intubation, difficult or impossible ventilation), and postextubation acute respiratory failure due to the formation of atelectases or to airway obstruction. The association of obstructive sleep apnoea syndrome (OSA) with obesity is very common, and induces a high risk of per and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre-, per- and postoperative pressure. For any obese patient, the implementation of difficult intubation protocols and the use of protective ventilation (low tidal volume 6–8 mL/kg of ideal body weight, moderate positive end-expiratory pressure of 10 cmH20, recruitment manoeuvres in absence of contra-indications), with morphine sparing and semi-seated positioning as much as possible are recommended, associated with a close postoperative monitoring. The dosage of anaesthetic drugs is usually based on the ideal body weight or the adjusted body weight and then titrated, except for succinylcholine that is dosed according to the total body weight. Monitoring of neuromuscular blockers should be used where appropriate, as well as monitoring of the depth of anaesthesia, especially when total intravenous anaesthesia is used in association with neuromuscular blockers. The occurrence of intraoperative awareness is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolism and early mobilisation are recommended, if possible included in an early rehabilitation protocol, to further reduce postoperative complications

An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study

International audienceObjective: To determined whether the implementation of an intubation management protocol leads to the reduction of intubation-related complications in the intensive care unit (ICU). Design: Two-phase, prospective, multicenter controlled study. Setting: Three medical-surgical ICUs in two university hospitals. Patients: Two hundred three consecutive ICU patients required 244 intubations. Interventions: All intubations performed during two consecutive phases (a 6-month quality control phase followed by a 6-month intervention phase based on the implementation of an ICU intubation bundle management protocol) were evaluated. The ten bundle components were: preoxygenation with noninvasive positive pressure ventilation , presence of two operators, rapid sequence induction, cricoid pressure, capnography, protective ventilation, fluid loading, preparation and early administration of sedation and vasopressor use if needed. Measurements and main results: The primary end points were the incidence of life-threatening complications occurring within 60 min after intubation (cardiac arrest or death, severe cardiovascular collapse and hypoxemia). Other complications (mild to moderate) were also evaluated. Baseline characteristics, including demographic data and reason for intubation (mainly acute respiratory failure), were similar in the two phases. The intubation procedure in the intervention phase (n = 121) was associated with significant decreases in both life-threatening complications (21 vs. 34%, p = 0.03) and other complications (9 vs. 21%, p = 0.01) compared to the control phase (n = 123). Conclusions: The implementation of an intubation management protocol can reduce immediate severe life-threatening complications associated with intubation of ICU patients

Percutaneous thermal ablation of hepatocellular carcinomas located in the hepatic dome using artificial carbon dioxide pneumothorax: retrospective evaluation of safety and efficacy

International audienceIntroduction: The targeting of hepatocellular carcinomas (HCC) in the hepatic dome can be challenging during percutaneous thermal ablation (PTA). The aims of this study were (1) to evaluate the safety and efficacy of PTA of HCC in the hepatic dome that cannot be visualized under US, using artificial CO2 pneumothorax and CT-guidance and (2) to compare the results with US-visible HCC located in the liver dome treated under US-guidance.Materials: Over a 32-month period, 56 HCC located in the hepatic dome were extracted from a prospectively maintained database. Twenty-eight cases (US-guidance group) were treated under US-guidance, while the others (n = 28, CT-CO2 group) were treated under CT-guidance using artificial CO2 pneumothorax after lipiodol tagging of the tumor. The primary technical success and complications rates of this technique were retrospectively assessed. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), local recurrence-free survival (LRFS) and overall survival (OS) were also compared between both groups.Results: Primary technical success was 100% in both groups. No major complications occurred. After a median follow-up of 13.8 months (range, 1–33.4 months), LTP occurred in 10.7% (3/28) in CT-CO2 vs. 25% (7/28) in the US-guidance group (p = NS). IDR occurred in 39.3% (11/28) in CT-CO2 vs. 28.6% (8/28) in the US-guidance group (p = NS). Death occurred in 17.9% (5/28) of patients in both groups. LRFS and OS did not significantly differ using Kaplan-Meier survival estimates.Conclusion: CT-guided PTA after artificially induced CO2 pneumothorax is a safe and efficient technique to treat HCC located in the hepatic dome

Automated oxygen administration versus conventional oxygen therapy after major abdominal or thoracic surgery: study protocol for an international multicentre randomised controlled study

International audienceIntroduction Hypoxemia and hyperoxia may occur after surgery with potential related complications. The FreeO2 PostOp trial is a prospective, multicentre, randomised controlled trial that evaluates the clinical impact of automated O2 administration versus conventional O2 therapy after major abdominal or thoracic surgeries. The study is powered to demonstrate benefits of automated oxygen titration and weaning in term of oxygenation, which is an important surrogate for complications after such interventions.Methods and analysis After extubation, patients are randomly assigned to the Standard (manual O2 administration) or FreeO2 group (automated closed-loop O2 administration). Stratification is performed for the study centre and a medical history of chronic obstructive pulmonary disease (COPD). Primary outcome is the percentage of time spent in the target zone of oxygen saturation, during a 3-day time frame. In both groups, patients will benefit from continuous oximetry recordings. The target zone of oxygen saturation is SpO2=88%–92% for patients with COPD and 92%–96% for patients without COPD. Secondary outcomes are the nursing workload assessed by the number of manual O2 flow adjustments, the time spent with severe desaturation (SpO2 98%), the time spent in a hyperoxia area (SpO2 >98%), the VO2, the duration of oxygen administration during hospitalisation, the frequency of use of mechanical ventilation (invasive or non-invasive), the duration of the postrecovery room stay, the hospitalisation length of stay and the survival rate

Medical Versus Surgical ICU Obese Patient Outcome : A Propensity-Matched Analysis to Resolve Clinical Trial Controversies

International audienceTo determine the short- and long-term mortality of obese ICU patients following medical as opposed to surgical admission and the relation between obesity and mortality.None

Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

International audienc